ELC001 Apprentice Electrician License Application

APPRENTICE ELECTRICIAN LICENSE APPLICATION INSTRUCTIONS

DOCUMENTS SUBMITTED WITH YOUR APPLICATION WILL NOT BE RETURNED. KEEP A COPY OF YOUR COMPLETED APPLICATION, ALL ATTACHMENTS, AND YOUR CHECK OR MONEY ORDER.

1. NAME ? Provide your legal name in the spaces provided. (Last, First, Middle Name, Suffix) Examples of a suffixinclude Jr., Sr., and II. (Mr. is not a suffix.)

2. DATE OF BIRTH ? Provide your birthdate.

3. GENDER ? Select whether you are male or female.

4. SOCIAL SECURITY NUMBER ? Social Security number disclosure is required by Section 231.302(1) of the Texas Family Code in order to obtain a license. Your social security number is subject to disclosure to an agency authorized to assist in the collection of child support payments. For more information regarding child support payments, contact the Texas Attorney General or call (512) 460-6000 or (800) 252-8014.

5. MAILING ADDRESS ? Provide your current mailing address. This is the address where we will send you mail. This address can be a post office box. You can add the zip plus-4 to help the postal service deliver mail more efficiently and accurately.

6. PHYSICAL ADDRESS ? Provide your physical address of your residence. Do not use a post office box for this address.

7. PHONE NUMBER ? Provide a telephone number, including the area code, where we can reach youduring the day. This may be your office phone number where we can leave a message.

8. EMAIL ADDRESS ? By providing my email address I authorize the Texas Department of Licensing and Regulation (TDLR) to send licensing communications and required notices to me by electronic mail. I understand that I may revoke this authorization in writing and that I must update my email address, or I will not receive these notices. I understand that the email address I have provided in this application will remain confidential except as permitted or required by law.

9. CRIMINAL HISTORY ? Indicate if you have ever been convicted of, or placed on deferred adjudication for, anyMisdemeanor or Felony, other than a minor traffic violation. If YES, complete and attach a Criminal History Questionnaire (PDF) for each offense. If you are worried your criminal history could prevent you from getting this license, Texas allows you to have your criminal history evaluated before you submit your application and pay non-refundable fees. To request a criminal history evaluation, submit a Criminal History Evaluation Letter (PDF), a completed Criminal History Questionnaire (PDF) for each crime you were convicted of, or placed on deferred adjudication for, and a $10.00 fee.

10. DISCIPLINARY ACTION HISTORY ? Indicate if you have ever had a professional license, certification, or registration suspended, revoked, or denied in any state. If Yes, complete and attach a Disciplinary Action Questionnaire (PDF) for each disciplinary action.

11. STATEMENT OF APPLICANT ? Carefully read the statement before dating and signing your application.

APPLICATION INFORMATION FOR MILITARY SERVICE MEMBERS, MILITARY VETERANS AND MILITARY SPOUSES The Texas Department of Licensing and Regulation recognizes the contributions of our active-duty military service members, their spouses, and veterans. If you want to use one of the licensing options available to military service members, military veterans and military spouses, please complete the Military Service Member, Military Veteran or Military Spouse Supplemental Application (PDF) and attach it with your license application.

If you have additional questions about qualifications, training or experience requirements relating to occupation licensing for military service members, military veterans or military spouses please go to the TDLR Military Information web page.

SEND YOUR COMPLETED APPLICATION AND REQUIRED DOCUMENTS TO:

Texas Department of Licensing and Regulation P.O. Box 12157 Austin, TX 78711-2157

Documents submitted with your application will not be returned. Keep a copy of your completed application, all attachments, and you check or money order. Do not send cash.

For additional information and questions, please visit the TDLR website. You can request assistance or submit required attachments via TDLR webform or fax (512) 463-9468. You may contact Customer Service Representatives by calling (800) 803-9202 (in state only) or (512) 463-6599; Relay Texas -TDD (800) 735-2989. Customer Service Representatives are available Monday through Friday from 7:00 a.m. until 6:00 p.m. Central Time (excluding holidays).

TDLR Public Information Act Policy: This document is subject to the Texas Public Information Act. With certain exceptions, information in this document may be made available to the public. For more information, view the TDLR Public Information Act Policy.

APPRENTICE ELECTRICIAN LICENSE APPLICATION

YOU MUST MEET ALL REQUIREMENTS WITHIN 12 MONTHS OF THE FILING DATE, OR THE APPLICATION WILL BE TERMINATED.

APPLICATION FEE: $20 (FEE IS NON-REFUNDABLE)

1. Name:

2. Date of Birth:

Last, First, Middle Name, Suffix

3. Gender:

Month / Day / Year

4. Social Security Number:

(See instruction sheet for disclosure information)

5. Mailing Address: (Used to receive mail from TDLR) (PO box is allowed for this address)

Male

Female

Number, Street Name, Suite Number/Apartment Number

City, State, Zip Code

6. Physical Address: (PO box is not allowed for this address)

7. Phone Number:

Number, Street Name, Suite Number/Apartment Number

City, State, Zip Code

8. Email Address:

(Area Code) Phone Number

(Ex: johndoe@) See instruction sheet for disclosure information

9. Have you ever been convicted of, or placed on deferred adjudication for, any misdemeanor or felony, other than a minor traffic violation?

If YES, complete and attach a Criminal History Questionnaire for each offense.

Yes No

See instruction sheet for more information

10. Have you ever had an occupational license, certification or registration suspended, revoked, or denied in any state?

If YES, attach a Disciplinary Action Questionnaire to this application. (This does not include your driver license.)

Yes No

11.

STATEMENT OF APPLICANT

I certify that I have read and will comply with all applicable provisions of the Electrician Act; Texas Occupation Code, Chapter 1305 and Chapter 51;Texas Administrative Code, Chapter 60; and the Electricians Administrative Rules, Texas Administrative Code, Chapter 73. I understand that providing false information on this application may result in denial of this application and/or revocation of the license I am requesting and the imposition of administrative penalties.

_______________________________ Date Signed

TDLR Form ELC001 rev June 2021

___________________________________________________________ Signature of Applicant

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